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Chapter 8
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8.1 Anatomy of the Sphenopalatine
and Maxillary Arteries 76
Sphenopalatine and
Maxillary Arteries
8.2 Indications for Approaches to
the Sphenopalatine and
Maxillary Arteries 77
8.3 Surgical Approach to the
Sphenopalatine Artery 78
8.4 Surgical Approach to the
Maxillary Artery 79
8.5 Complications 82
Sphenopalatine and Maxillary Arteries
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8 Sphenopalatine and Maxillary Arteries
David K. Morrissey, Peter John Wormald
Introduction
This chapter describes the anatomy of the sphenopalatine and internal maxillary arteries in detail to provide a
framework for the surgical management of these regions.
Techniques for the endonasal endoscopic approach to the
sphenopalatine artery (SPA) are discussed. Approaches to
the maxillary artery within the pterygopalatine fossa are
also discussed including the transantral approach. Complications of these approaches as well as tips and pitfalls
are also highlighted.
SPA
8.1 Anatomy of the Sphenopalatine and Maxillary Arteries
8.1.1 Maxillary Artery
The maxillary artery is one of two large terminal branches
of the external carotid artery and arises deep to or within
the parotid gland, below the level of the temporomandibular joint. It then passes horizontally between the sphenomandibular ligament and the ramus of the mandible
to cross the lower head of the lateral pterygoid muscle
where it is embedded within the pterygoid venous
plexus. Next it enters the pterygomaxillary fissure and
runs posterior to the posterior wall of the maxillary sinus
and terminates by entering the nasal cavity as the SPA via
the sphenopalatine foramen (Fig. 8.1).
The maxillary artery is typically described as having
three parts based on its relationship to the lateral pterygoid muscle. The first part lies medial to the mandible
and lateral to the lateral pterygoid muscle and typically
has four branches. The second part is the portion crossing
the lateral pterygoid muscle and typically has six muscular branches and a variable relationship to that muscle.
The third portion of the maxillary artery is the part of
most interest to the rhinologist. It enters the pterygopalatine fossa via the pterygomaxillary fissure. Within the
pterygopalatine fossa, the artery runs a torturous course
and gives off several branches, coming to an end as it exits
the sphenopalatine foramen as the SPA.
demonstrated five arteries arising from the third part of
the maxillary artery commencing at a level of one-third
the height of the posterior maxillary wall. These were the
posterior superior alveolar, infraorbital, pterygoid canal,
descending palatine, and sphenopalatine arteries, with
their origins occurring in this order from lateral to medial
in 85% of cases.
The third part of the maxillary artery passes in an
anteromedial superior direction upon entering the pterygopalatine fossa (Fig. 8.2). Within the pterygopalatine
fossa, the course of the maxillary artery can be described
as looped (most common), bifurcated, or straight. As the
maxillary artery traverses the pterygopalatine fossa, it is
always located anterior to the neural elements, and the
terminal division occurs in the medial superior third in
60% of cases and the middle medial third in 30% of cases,
1
Choi and Park2
MAX
VP
LP
Fig. 8.1 The second and third parts of the right maxillary
artery (MAX) demonstrated in a coronal view of a cadaveric
dissection. The artery can be seen to cross the lateral pterygoid
muscle (LP), with the interlaced pterygoid venous plexus
(VP) closely related. The sphenopalatine artery (SPA) can
be seen in the top right of the dissection dividing into two
terminal branches within the pterygopalatine fossa. (Image
and dissection are provided courtesy of Dr. Rowan Valentine,
Adelaide, Australia.)
with occasional divisions elsewhere within the pterygopalatine fossa. The configuration of the terminal branches
of the maxillary artery is also quite variable and can take
several different formats, also previously described by
Choi and Park.
it is difficult to predict the individual variation that will be
encountered in any particular case; hence, it is incumbent
upon the surgeon to expect wide variation in the course
of the maxillary artery and its branches and to operate in
such a manner as to account for possible variations.
2
While these descriptions are a helpful aid,
8.1.2 Sphenopalatine Artery
The SPA is the terminal branch of the maxillary artery and
supplies the mucosa of the nasal septum and lateral nasal wall. It enters the nasal cavity via the sphenopalatine
foramen (Fig. 8.3) and divides into posterior lateral nasal
and posterior nasal arteries. The larger of the branches is
76
ION
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Sphenopalatine and Maxillary Arteries
LP
MAX
Fig. 8.2 The third part of the left maxillary artery (MAX)
demonstrated within the pterygopalatine fossa in a cadaveric
dissection. The posterior wall of the maxillary sinus has been
removed. The artery can be seen crossing the medial aspect
of the lateral pterygoid muscle (LP) where it becomes the
third part of the artery. Its tortuous course is apparent in
this dissection, as is its relationship with the neural elements
including the infraorbital nerve (ION). (Image and dissection
are provided courtesy of Dr. Rowan Valentine, Adelaide,
Australia.)
the posterior lateral nasal branch, which goes on to supply the middle and inferior turbinates. The posterior nasal branch crosses the anterior face of the sphenoid sinus
below the level of the sphenoid ostium before dividing
into branches on the septum.
1
It is the vessel commonly
encountered during endoscopic sinus surgery as the surgeon opens the sphenoid sinus inferiorly and is the critical vascular supply for the nasoseptal flap.
The sphenopalatine foramen is located on the lateral
wall of the nose at the level of or within 10 mm of the
posterior wall of the maxillary sinus.
3
It is bounded
superiorly by the body of the sphenoid bone, while the
palatine bone forms the anterior, posterior, and inferior
borders via its orbital process, perpendicular plate, and
sphenoidal processes, respectively. The crista ethmoidalis
(Fig. 8.3) is a reliable lateral nasal wall landmark for the SPA
and is formed by a small bony crest of the perpendicular
plate or ascending process of the palatine bone that meets
the most posterior, inferior, and lateral aspect of the
middle turbinate.
4
It typically lies immediately anterior to
the anteroinferior aspect of the sphenopalatine foramen
and on occasion is directly inferior. It can be used as a
landmark for SPA ligation. Wareing et al.
5
demonstrated
that the location of the sphenopalatine foramen can be
within the middle meatus, superior meatus, or transition
region between the two.
The sphenopalatine foramen is approximately 6 mm
in vertical dimension and often takes an hourglasstype shape.
demonstrated to be present in 10 to 13% of cases by
several authors.
located anterior and inferior to the true foramen.
3
Accessory sphenopalatine ostia have been
6,7
Accessory foramina are typically
5
*
SPA
Fig. 8.3 Sphenopalatine artery (SPA) as it exists the right
sphenopalatine foramen. Note the bony ridge of the crista
ethmoidalis (*) immediately anterior and superior to the
exiting vessel.
Within the sphenopalatine foramen, the SPA divides
into its branches in 80% of cases prior to the passage of the
vessel into the nasal cavity.
multiple branches emanating from the foramen at its entry
point into the nasal cavity. Simmen et al
6
Consequently, there are often
8
have demonstrated
that 97% of specimens had two or more branches and 64%
had three or more. Typically, there are two major branches.
This is a key observation, as successful ligation of the SPA
at the foramen typically requires multiple branches to be
addressed. Failure to do so is proposed to be a significant
reason for failed management of posterior epistaxis via
endoscopic SPA ligation.
9
8.2 Indications for Approaches
to the Sphenopalatine and
Maxillary Arteries
There are several indications for utilizing direct surgical
approaches to the sphenopalatine and maxillary arteries.
These indications include:
• Posterior or refractory epistaxis.
• Surgery for benign and malignant neoplasms of the para-
nasal sinuses, nasal cavity, and pterygopalatine fossa.
• As part of the initial approach to the vidian nerve in the
pterygoid canal.
Furthermore, approaches toward the sphenopalatine and
maxillary arteries may form an important part of several
extended endoscopic endonasal approaches involving the
following sites:
• Lateral recess of the sphenoid sinus.
• Cavernous sinus and middle cranial fossa.
• Pterygopalatine and infratemporal fossa.
• Posterior cranial fossa.
• Petrous temporal bone.
The choice of approach is largely dictated by the particular pathology, its anatomic extent, and the fundamental
need of the surgeon to have adequate exposure to operate
safely and efficiently.
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8.3 Surgical Approach to the
Sphenopalatine Artery
The SPA is typically approached under a general anesthesia. In occasional instances where a patient is not fit
for general anesthesia, the approach may be conducted
under local anesthetic.
In both instances, the nose is prepared with injection of
local anesthetic with adrenaline, in particular addressing
the mucosa in the surgical field located above the inferior
turbinate within the middle meatus. Topical vasoconstrictor (if possible, cocaine < 3 mg/kg with adrenaline 1:10,000)
is also applied via cottonoids to the mucosa within the surgical field and along the operative channels (nasal septum
and inferior turbinates). Preparation of the nose in this
manner prior to the surgical scrub allows the full benefits
of the topical and injected agents to be realized and hence
the patience of the surgeon is rewarded with an improved
surgical field. In instances where there is temporary nasal
packing in place maintaining hemostasis, the surgeon may
elect to perform the preparation of the nose once all equipment is prepared and the surgeon has performed a surgical
scrub and established a sterile surgical field.
Once the surgical scrub has been completed and a
sterile surgical field established, the surgeon may elect to
infiltrate additional local anesthetic with adrenaline via
Mucosal
flap
Inferior
turbinate
Fig. 8.4 A cadaveric specimen demonstrating the mucosal
fl ap recommended for a left sphenopalatine artery ligation.
(Image and dissection are provided courtesy of Dr. Rowan
Valentine, Adelaide, Australia.)
10
Wormald.
vasoconstriction of the SPA and may be of particular
benefit in the management of posterior epistaxis and
those patients with an ongoing anticoagulant need. To
perform this infiltration, the surgeon places his or her
finger into the mouth and palpates the hard palate in
the region of the second upper molar tooth. A depression
should be felt indicating the entry point to the canal.
Using an endoscope, the surgeon can identify the position
of the foramen visually and maintain this visualization
for introduction of the needle. A 25-G needle, bent to 45
degrees at 25 mm from the tip of the needle, is introduced
into the foramen at the previously identified position and
then advanced to the point of the bend. At this point,
2 mL of local anesthetic with adrenaline is infiltrated.
Often, but not always, the ipsilateral hard palate mucosa
will be seen to blanch following the injection, which is a
reassuring indication of correct placement.
At the commencement of the procedure, a septoplasty
may be needed in some instances to access the middle
meatus, and this should be performed before any procedure upon the SPA is begun. Once the middle meatus is
easily accessible, the endoscope is passed into the middle
meatus, and the posterior fontanelle of the lateral nasal
wall is identified as an anterior landmark for surgery
via palpation of the lateral nasal wall within the middle
meatus. The posterior fontanelle is a site within the wall
separating the maxillary sinus and nasal cavity where the
mucosa is intact but the bone deficient. A vertical incision is then made with a no. 15 blade scalpel on a 7 BP
handle just posterior to the fontanelle onto the palatine
bone from the upper part of the middle meatus and carried down to the level of the inferior turbinate insertion.
Horizontal incisions are made at the top and bottom of
this incision to allow the elevation of a posteriorly based
nasal mucosal flap (Fig. 8.4). A suction Freer elevator is
used to elevate this flap. Malleable instrumentation can
be an advantage at this stage if available. It is important
This can enhance the surgical field by inducing
to ensure the surgeon is directly dissecting onto the bone,
as dissection in this surgical plane greatly simplifies the
procedure. Dissection should be commenced at the inferior aspect of the flap and gradually elevated posteriorly
and superiorly.
As the dissection progresses, the crista ethmoidalis
will be approached just anterior to the sphenopalatine
foramen. This can be easily removed with a Hajek-Koffler
punch or similar instrument, being careful not to damage
the sphenopalatine neurovascular bundle. To avoid this
problem, ensure that the instrument is firmly engaged
upon the bone prior to removal of the crest. Upon closure
of the instrument, be sure to fully release the instrument
from the dissected bone. This permits the release of the
artery if inadvertently captured in the device and significantly reduces the risk of avulsion or tear to the vessel
as can be seen when the instrument is engaged and then
directly removed from the nasal cavity. Bone fragments
noted after release can be removed at this point via a simple grasping instrument.
Immediately posterior to the crest, the SPA will be enco
untered as it exits the sphenopalatine foramen. At this
site, it should be carefully isolated from the surrounding
connective tissue. A sickle knife or suction Freer is
commonly employed for this task. Once identified
along a suitable length, it is our practice to use suction
bipolar forceps to diathermize the vessel. The vessel
is then divided, and dissection continues posteriorly
and superiorly to identify further branches of the SPA
and importantly the posterior nasal artery (Fig. 8.5
and 8.6). As they are encountered, these vessels are
coagulated with bipolar electrocautery and divided.
At the conclusion of the dissection, the divided vessel
stumps will be discernable on the lateral nasal wall and
the lateral aspect of the anterior face of the sphenoid
clean and visible at the posterior aspect of the dissection.
In some instances, vascular clips may be utilized to aid
hemostasis. It is our preference to use bipolar cautery
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PNA
SPA
stump
Fig. 8.5 An additional minor branch of the right
sphenopalatine artery is noted posterior to the stump of the
sphenopalatine artery (SPA).
in all instances, including when clips are utilized, as
inadequately placed clips can become dislodged and lead
to bleeding intraoperatively or postoperatively.
The mucosal flap is then replaced and a small piece of
Surgicel placed over the flap to maintain its position. The
patient is usually able to be discharged 12 to 24 hours
postprocedure and is sent home on 6 hourly nasal saline
douches and with a 5- to 10-day course of oral antibiotics.
SPA branch
8.3.1 Tips and Tricks
• Preoperative nasal packing allows temporary control of
posterior epistaxis and additionally tends to improve
the width of the endonasal corridor for surgical access.
• In posterior epistaxis, the utilization of a local anes-
thetic injection via the greater palatine canal improves
hemostasis and facilitates surgery around the spheno-
palatine foramen.
• Techniques to improve hemostasis intraoperatively
such as elevation of the head of the bed should be uti-
lized.
• Dissection in the correct subperiosteal plane of the lat-
eral nasal wall greatly simplifies the procedure.
• All vessels should be subjected to bipolar electrocau-
tery to ensure hemostasis.
• At the conclusion of the procedure, the vessel stumps
should be easily visible and the anterior face of the
sphenoid cleanly dissected to ensure no vessels are
missed.
8.4 Surgical Approach to the
SPA stump
Sphenoid
anterior face
Fig. 8.6 Right posterior nasal artery (PNA) seen on the
anterior face of the sphenoid sinus. SPA, sphenopalatine artery.
however, the SPA ligation technique has largely superseded this indication.
After induction of general anesthesia, the nose is prepared via injection of local anesthetic with adrenaline
to the septum, middle turbinate, and axilla regions. Cottonoids soaked in topical vasoconstrictor are then placed
within the middle meatus. Ideally, this is completed prior
to the surgical scrub to allow the vasoconstrictor to take
effect. The skin is then prepared with topical antiseptic
and sterile drapes are applied.
At the commencement of the procedure, a septoplasty is performed if necessary for access. The middle turbinate is then gently medialized using a light pressure
from a Freer elevator. Landmarks within the middle meatus for this approach are identified in Fig. 8.7. A releasing incision can be made at the medial inferior aspect of
the junction between the horizontal and vertical ground
lamellae to aid medialization of the middle turbinate.
BE
UP
MT
Septum
FP
Maxillary Artery
8.4.1 Transantral Approach
The transantral approach allows access to the medial
portion of the posterior wall of the maxillary sinus and
hence the medial elements of the maxillary artery and
its terminal branches. Intractable posterior epistaxis was
formerly the most common indication for this procedure;
Fig. 8.7 Left middle meatus demonstrating the middle
turbinate (MT), bulla ethmoidalis (BE), uncinate process (UP),
and frontal process of the maxilla (FP).
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A “swing door” uncinectomy is then performed. The hiatus semilunaris may be identified initially with a ball
probe. Then, under direct vision, a sickle knife is used to
incise through the superior edge of the uncinate process.
It is important that this incision is carried through all
three layers (mucosa/bone/mucosa). This incision is then
taken anteriorly until the hard bone of the frontal process
of the maxilla is reached. Next, a backbiter is passed into
the semilunar hiatus, taken as inferiorly as possible within the hiatus and then utilized to incise the inferior aspect
of the uncinate, again moving anteriorly until the fron-
UP
MT
FP
tal process of the maxilla is reached. The final cut with
this instrument can be directed superiorly to facilitate
uncinate removal (Fig. 8.8a). A ball probe is then placed
under the lower of the two incisions and rotated into a
vertical orientation. While maintaining close opposition
to the lateral nasal wall, the ball probe is drawn forward
to “swing” the uncinated process anteriorly and facilitate
its removal (Fig. 8.8b). The removal is completed using
a 45-degree through-cutting Blakesley forceps applied
closely to the lateral wall of the nose and again taking all
three layers of the mucosa (Fig. 8.8c).
MT UP
a
UP
MT
c
b
Fig. 8.8 (a) Incisions made for a left swing-door uncinectomy. The uncinate process (UP), middle turbinate (MT), and frontal process
(FP) of the maxilla are demonstrated. (b) Left uncinate process swung out into position for removal with an upturned through-cutting
Blakesley forceps. MT, middle turbinate; UP, uncinate process. (c) Removal of the left uncinate process (UP) via 45-degree throughcutting Blakesley forceps. MT, middle turbinate.
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*
Fig. 8.9 Natural ostium of the left maxillary sinus (*) adjacent
to the anterior aspect of the horizontal portion of the uncinate
process (indicated by ball probe).
Upon completing the uncinate removal, the 30-degree
endoscope will allow visualization of the natural ostium
of the maxillary sinus (Fig. 8.9). This is typically located
anteriorly and is often difficult to appreciate without the
angled endoscope. Next, a straight or 45-degree Blakesley through-cutting forceps is used to enlarge the natural
ostium. The upper cutting arm is placed into the natural ostium and the posterior wall of the natural ostium is
divided. This cut is then taken posteriorly to the posterior
wall of the maxillary sinus. A combination of instruments
and the microdebrider are used to maximize the opening
into the maxillary sinus. The completed opening should
extend from the anterior aspect of the natural ostium in
a posterior direction to the posterior wall of the maxillary sinus and vertically from the superior aspect of the
inferior turbinate up to the inferomedial wall of the orbit
(Fig. 8.10). Any accessory maxillary sinus ostia should be
incorporated into the unified ostium.
At this point, the medial aspect of the posterior wall
of the maxillary sinus will be seen with a zero-degree
endoscope.
8.4.2 Dissection of the Posterior
Wall of the Maxilla and Identifi -
cation of the Maxillary Artery
Once the desired extent of the posterior wall of
the maxillary sinus is exposed, entry into the
pterygopalatine fossa can be commenced. Initially, a
Freer elevator is placed gently against the bone of the
posterior wall and a light pressure used to fracture
the wall (Fig. 8.11). The Freer elevator or ball probe
can then be used to flake off some initial fragments of
bone. Where the bone is quite thin, this technique is
effective; however, as the bone thickens, the surgeon
will need to utilize a Hajek-Koffler or Kerrison punch
for the bone removal (Fig. 8.12). Bone removal should
occur in the plane above the level of the periosteum
and extend over a wide region of the maxillary sinus
Fig. 8.10 Widely open left maxillary antrum with the
posterior wall of the maxillary sinus easily visible.
Fig. 8.11 A Freer elevator is used to gently fracture the
posterior wall of the right maxillary sinus (cadaveric specimen).
posterior wall. Superiorly, the surgeon needs to be
mindful of the infraorbital nerve as it enters the
maxillary sinus roof. Typically, the surgeon should aim
to remove the majority of the posterior wall of the sinus
to facilitate the best possible access to the contents of
the pterygopalatine and infratemporal fossa.
After exposure, the periosteum of the posterior maxillary wall is incised with a sickle knife. Typically, fat will
herniate through the incision into the posterior aspect of
the maxillary sinus. The maxillary artery has a convoluted
and somewhat unpredictable course within the pterygopalatine fossa as described earlier and demonstrated in
Figs. 8.1 and 8.2. It is, however, reliably located anterior
to the neural structures. Once identified, branches should
be followed in both directions until the main artery is
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Fig. 8.12 A Kerrison punch is used to remove the bone of the
posterior wall of the right maxillary sinus (cadaveric specimen).
identified. The artery can then be clipped and/or or coagulated via bipolar diathermy and then divided. Individual
branches may also require bipolar cautery due to the significant anastomoses and consequent backflow. Fat of the
pterygopalatine fossa may be gently removed to identify
the neurologic structures within the fossa and to reveal
the pterygoid process of the sphenoid. This facilitates
approaches to the lateral sphenoid, infratemporal fossa,
and middle cranial fossa.
8.4.3 Tips and Tricks
• The maxillary artery can be identified in a retrograde
fashion:
– Identify the SPA at the SPA foramen and remove the
posterior wall of the maxilla from medial to lateral.
– Follow the vessel back to the terminal division to
identify the main trunk.
• A greater palatine canal block may improve hemostasis
within the pterygopalatine fossa and hence aid the surgeon in visualization of the surgical field.
• To obtain access further laterally, an endoscopic medial
maxillectomy or prelacrimal approach (discussed elsewhere in this title) may be of benefit.
• The surgeon should avoid the use of powered instru-
mentation in the removal of the uncinate process as
the lamina papyracea is positioned immediately lateral
to the uncinate and can be inadvertently damaged in
this region. This is particularly important in instances
where the uncinate process is lateralized or adhered to
the lamina papyracea.
8.5 Complications
The complications of approaches to the sphenopalatine
and maxillary arteries via endoscopic techniques are
similar to those experienced for any endoscopic sinus
procedure. In the majority of cases, the SPA ligation technique is utilized for recurrent posterior epistaxis; hence,
recurrence of the epistaxis is the complication of most
interest. To that end, numerous studies have reported
success rates of 92 to 100% with endoscopic SPA ligation
for posterior epistaxis.
Minor complications include:
• Synechia.
• Postoperative infection.
• Recurrent or persistent epistaxis.
• Minor postoperative pain.
• Epiphora.
Major complications of surgery within the pterygopalatine
fossa include:
• Facial pain.
• Midfacial anesthesia or paraesthesia.
• Dental anesthesia or paraesthesia.
• Reduced lacrimation.
• Injury to the sphenopalatine ganglion or vidian nerve.
• Blindness and ophthalmoplegia.
References
1. Hollinshead WH. Anatomy for Surgeons: The Head and Neck. New
York, NY: Harper & Row; 1982
2. Choi J, Park HS. The clinical anatomy of the maxillary artery in the pterygopalatine fossa. J Oral Maxillofac Surg
2003;61(1):72–78
3. Prades JM, Asanau A, Timoshenko AP, Faye MB, Martin Ch. Surgical
anatomy of the sphenopalatine foramen and its arterial content.
Surg Radiol Anat 2008;30(7):583–587
4. Bolger WE, Borgie RC, Melder P. The role of the crista ethmoidalis in endoscopic sphenopalatine artery ligation. Am J Rhinol
1999;13(2):81–86
5. Wareing MJ, Padgham ND. Osteologic classification of the sphenopalatine foramen. Laryngoscope 1998;108:125–127
6. Midilli R, Orhan M, Saylam CY, Akyildiz S, Gode S, Karci B.
Anatomic variations of sphenopalatine artery and minimally
invasive surgical cauterization procedure. Am J Rhinol Allergy
2009;23(6):e38–e41
7. Antunes Scanavini AB, Navarro JAC, Megale SRMC, Lima RS,
Anselmo-Lima WT. Morphometric evaluation of the sphenopalatine foramen for endonasal surgery. Rhinology 2010;48(4):
441–445
8. Simmen DB, Raghavan U, Briner HR, Manestar M, Groscurth
P, Jones NS. The anatomy of the sphenopalatine artery for the
endoscopic sinus surgeon. Am J Rhinol 2006;20(5):502–505
9. Wormald PJ, Wee DT, van Hasselt CA. Endoscopic ligation of the
sphenopalatine artery for refractory posterior epistaxis. Am J
Rhinol 2000;14(4):261–264
10. Douglas R, Wormald PJ. Pterygopalatine fossa infiltration
through the greater palatine foramen: where to bend the needle.
Laryngoscope 2006;116(7):1255–1257
11. Li J, Xu X, Wang J, Jing X, Guo Q, Qiu Y. Endoscopic study for the
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944–947
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Section 3
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9 Transcribriform Approach 85
Anterior Cranial Fossa
10 Endoscopic Transtuberculum
Transplanum Approach 93
11 Suprasellar Approach to
the Third Ventricle 105
12 Endoscopic Sellar Approach 117
13 Cavernous Sinus Approach 127
14 Endonasal Endoscopic–
Assisted Intraorbital
Approach 141
15 Transorbital Neuroendoscopic
Approach 151
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